Comprehensive Internal Medicine Study
Guide, Practice Questions, Answers, and
Detailed Rationales for In-Training Exam
Preparation 2025/2026
What is a positive stress test - answers Flat or Down sloping
St-segment depression >1 mm
occurring 80 msec after j point
When to stop a stress test - answers St segment depression > 2 mm,
ventricular tachycardia,
drop in SBP > 15,
CP,
dyspnea,
lightheadedness
Stress test of choice with a LBBB or ventricular pacing? - answers Myocardial perfusion
imaging with adenosine,
NOT exercising!
When to not use doutamine for stress - answers History of VT,
severe HTN,
Low BP,
poor echo images
When to not use adenosine for stress - answers Bronchospasm,
severe valvular dysfunction,
severe carotid stenosis,
2nd degree heart block, t
heophylline dependent
Normals for PA catheter pressures - answers RA <8
RV 30/8
PCWP 3-12
PAP 12--12
Diastolic pressures
elevated & equalized
in all chambers,
low BP - answers tamponade
or restrictive pericarditis
Elevated RA and PA pressures,
,decreased or nl PCWP,
hypotension - answers RV MI
Elevated PCWP, RA pressure
decreased SBP/cardiac output - answers cardiogenic shock
high RA,
PA very elevated
high PCWP
nl SBP - answers mitral stenosis with RV failure
Elevated PAP, RAP
nl PCWP, SBP - answers pulmonary HTN
decr in SBP>10mmHg with nl inspiration;
palpated as weakened pulse with inspiration &
more heart contractions to pulse beats - answers pulsus paradoxus:
Constrictive or restrictive pericarditis,
asthma,
tension pneumothorax
What gives you pulsus bisferiens
(two systolic peaks per cycle) - answers Aortic regurgitation,
HOCM
What causes pulsus alternans - answers Severe LV dysfunction
What causes pulsus tardus - answers Aortic stenosis
How do positional maneuvers affect blood flow and murmurs - answers
-standing/valsalva:
decreased cardiac filling,
decreases most murmurs
except MVP and HOCM
-squatting/ lying down:
increase cardiac volume,
increased murmurs
except MVP, HOCM
-sustained handgrip:
increases systemic resistance
decreases murmur in HOCM, AS
What causes a physiologic split S2 - answers Increased blood volume in the RV
prolongs systole and
,delays pulmonary valve closure
What causes a fixed split S2 - answers Pulmonary stenosis,
PE,
LV pacer,
RBBB,
MR (early AV closure),
ASD,
RV failue
What causes a paradoxic split S2 - answers LBBB,
RV pacing,
HOCM
What causes an S3? - answers Rapid LV filling:
acute ventricular decompensation,
severe AR or MR
What are the parts of the venous waveform? - answers A wave - atrial contraction
X descent - atria relax, RV fills rapidly
Bottom of x descent is TC valve closure
V wave - ventricle contacting against closed TC valve
Y descent - TC valve opens,
passive emptying into ventricle
What gives elevated a and v waves - answers Pulmonary HTN,
RV infarction
Large r side v waves - answers Septal rupture
Large v waves - answers TR (right),
MR (left)
Rapid x and y descent - answers Constrictive pericarditis,
restrictive cardiomyopathy,
tamponade
(x descent only, loss of y descent)
Large a waves - answers TS,
severe RVH (on right),
MS
Cannon a waves - answers AV disassociation -
, complete heart block,
ventricular pacing
Slow Y descent - answers Delayed atrial emptying - TS
Most important prognostic factor with CAD - answers Degree of LV dysfunction
Causes of resting ST elevation - answers MI,
pericarditis,
LV aneurysm,
LBBB,
ventricular pacing,
LVH,
early repolarization
Hibernating myocardium - answers myocardium near the infarction may be
underperfused but not necrotic-
the metabolism of the cells adapts to low energy supplies & are nonfunctional
until perfusion is restored
Reperfusion injury - answers the re-estab of blood flow after a coronary artery is
blocked,
which may further damage the heart tissue due to the formation of O2 free radicals
Stunned myocardium - answers prolonged post ischemic dysfunction,
salvaged by reperfusion,
several days
NSTEMI have _____ initial mortality,
but have the _____ one year mortality as a STEMI - answers Lower,
Same
NSTEMI have a higher risk of these vs. STEMI - answers Persistent angina,
reinfarction, and
death within several months
MR due to papillary muscle rupture is most common with MI in this region - answers
Inferior
Types of arrythmias with IWMI - answers Junctional escape,
Mobitz I,
and they are usually temporary
Types of arrythmias with AWMI - answers Mobitz II,
BBB.
More of the myocardium is involved
Guide, Practice Questions, Answers, and
Detailed Rationales for In-Training Exam
Preparation 2025/2026
What is a positive stress test - answers Flat or Down sloping
St-segment depression >1 mm
occurring 80 msec after j point
When to stop a stress test - answers St segment depression > 2 mm,
ventricular tachycardia,
drop in SBP > 15,
CP,
dyspnea,
lightheadedness
Stress test of choice with a LBBB or ventricular pacing? - answers Myocardial perfusion
imaging with adenosine,
NOT exercising!
When to not use doutamine for stress - answers History of VT,
severe HTN,
Low BP,
poor echo images
When to not use adenosine for stress - answers Bronchospasm,
severe valvular dysfunction,
severe carotid stenosis,
2nd degree heart block, t
heophylline dependent
Normals for PA catheter pressures - answers RA <8
RV 30/8
PCWP 3-12
PAP 12--12
Diastolic pressures
elevated & equalized
in all chambers,
low BP - answers tamponade
or restrictive pericarditis
Elevated RA and PA pressures,
,decreased or nl PCWP,
hypotension - answers RV MI
Elevated PCWP, RA pressure
decreased SBP/cardiac output - answers cardiogenic shock
high RA,
PA very elevated
high PCWP
nl SBP - answers mitral stenosis with RV failure
Elevated PAP, RAP
nl PCWP, SBP - answers pulmonary HTN
decr in SBP>10mmHg with nl inspiration;
palpated as weakened pulse with inspiration &
more heart contractions to pulse beats - answers pulsus paradoxus:
Constrictive or restrictive pericarditis,
asthma,
tension pneumothorax
What gives you pulsus bisferiens
(two systolic peaks per cycle) - answers Aortic regurgitation,
HOCM
What causes pulsus alternans - answers Severe LV dysfunction
What causes pulsus tardus - answers Aortic stenosis
How do positional maneuvers affect blood flow and murmurs - answers
-standing/valsalva:
decreased cardiac filling,
decreases most murmurs
except MVP and HOCM
-squatting/ lying down:
increase cardiac volume,
increased murmurs
except MVP, HOCM
-sustained handgrip:
increases systemic resistance
decreases murmur in HOCM, AS
What causes a physiologic split S2 - answers Increased blood volume in the RV
prolongs systole and
,delays pulmonary valve closure
What causes a fixed split S2 - answers Pulmonary stenosis,
PE,
LV pacer,
RBBB,
MR (early AV closure),
ASD,
RV failue
What causes a paradoxic split S2 - answers LBBB,
RV pacing,
HOCM
What causes an S3? - answers Rapid LV filling:
acute ventricular decompensation,
severe AR or MR
What are the parts of the venous waveform? - answers A wave - atrial contraction
X descent - atria relax, RV fills rapidly
Bottom of x descent is TC valve closure
V wave - ventricle contacting against closed TC valve
Y descent - TC valve opens,
passive emptying into ventricle
What gives elevated a and v waves - answers Pulmonary HTN,
RV infarction
Large r side v waves - answers Septal rupture
Large v waves - answers TR (right),
MR (left)
Rapid x and y descent - answers Constrictive pericarditis,
restrictive cardiomyopathy,
tamponade
(x descent only, loss of y descent)
Large a waves - answers TS,
severe RVH (on right),
MS
Cannon a waves - answers AV disassociation -
, complete heart block,
ventricular pacing
Slow Y descent - answers Delayed atrial emptying - TS
Most important prognostic factor with CAD - answers Degree of LV dysfunction
Causes of resting ST elevation - answers MI,
pericarditis,
LV aneurysm,
LBBB,
ventricular pacing,
LVH,
early repolarization
Hibernating myocardium - answers myocardium near the infarction may be
underperfused but not necrotic-
the metabolism of the cells adapts to low energy supplies & are nonfunctional
until perfusion is restored
Reperfusion injury - answers the re-estab of blood flow after a coronary artery is
blocked,
which may further damage the heart tissue due to the formation of O2 free radicals
Stunned myocardium - answers prolonged post ischemic dysfunction,
salvaged by reperfusion,
several days
NSTEMI have _____ initial mortality,
but have the _____ one year mortality as a STEMI - answers Lower,
Same
NSTEMI have a higher risk of these vs. STEMI - answers Persistent angina,
reinfarction, and
death within several months
MR due to papillary muscle rupture is most common with MI in this region - answers
Inferior
Types of arrythmias with IWMI - answers Junctional escape,
Mobitz I,
and they are usually temporary
Types of arrythmias with AWMI - answers Mobitz II,
BBB.
More of the myocardium is involved
